Healthcare Provider Details

I. General information

NPI: 1336476795
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 13TH AVE S SUITE 215
JACKSONVILLE BEACH FL
32250-3230
US

IV. Provider business mailing address

1370 13TH AVE S SUITE 215
JACKSONVILLE BEACH FL
32250-3230
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-1041
  • Fax: 904-249-9764
Mailing address:
  • Phone: 904-249-1041
  • Fax: 904-249-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN WILBANKS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 904-376-4275